Mapping Greener HealthcareMapping Greener Healthcare

Routine monthly haemodialysis blood tests generate a very large amount of paper results (at least 20000 sheets of A4 paper per year for the approximately 160 patients on the DBH dialysis program). Such large volumes of paper result in significant clinical and administrative workload and a high risk of relevant reports being missed. All such results are reviewed electronically in the monthly dialysis MDT meetings. Given the costs and lack of utility of paper reports it was agreed with the Trust's medical director that paper reports for routine haemodialysis results could be switched off.

Details of implementationThe first step was to agree with the Trust's medical director that not having paper results did not create a risk to patient safety or a medico-legal problem. Once this had been agreed, the Medical Records department were informed to ensure that a record is kept of which notes are affected and what results are not being filed on paper.

The pathology IT manager assigned location codes to each dialysis unit and, in March 2012, set the pathology system to paperless reporting of haematology and biochemistry reports for these locations. Staff in the haemodialysis units and  pathology specimen reception were informed of the relevant codes to ensure samples are booked in correctly.

Benefits to environmental sustainabilityThe annual costs of printing 20,000 sheets of A4 paper (calculated using Hewlett-Packard's online tool) are:

• Energy 563 kWh
• Paper: 100kg
• Energy & paper CO2 emissions: 380kg CO2
• Energy & paper costs: £120

CKD management is predominantly data-driven. Considerable IT infrastructure is already in place that has enabled a remote CKD monitoring service for patients in Sheffield enabling devolved, patient centred care. A future renal database is likely to be able to increase the sophistication of such a disease management program. The start-up costs for such a model mainly consist of a salary for one clinical nurse specialist with modest consultant nephrologist support.

Current model of CKD care in Sheffield

The Sheffield Kidney Institute (SKI) in collaboration with primary care has introduced a number of measures to improve the recognition and management of chronic kidney disease (CKD) in the community whilst ensuring referrals to secondary care are ‘managed’ in an appropriate way.

These include:

1. Online guidelines covering both the referral and management of CKD in primary care.
2. Online educational package covering the management of CKD in primary care.
3. Allocation of 1 PA of consultant time to screen referrals and advise GPs about which patients can be managed in primary care with appropriate management plans. Since the start of this service in 2006 approximately 30% of referrals from primary care have been dealt with through advice and guidance thereby avoiding unnecessary trips to secondary care. This service meets a key UK Renal Association standard that renal units should provide a non-visit based advisory service for primary care.
4. In addition to the paper-based system above secure, electronic, consultant lead advice and guidance is available to primary through both the Choose and Book system as well through email via an nhs.net account.

Further to these measures, the SKI has identified a group of patients with CKD who currently remain under specialist kidney care but who could be effectively managed in primary care, with specialist support. These are patients with stable/slowly progressive but advanced CKD, who require regular biochemical and blood pressure monitoring, or who require specialist anaemia management.

The problem

Although the number of patients discharged to primary care has increased significantly, discharge rates from secondary care may be limited by concerns about whether patients can be reliably locked into a disease management programme in primary care. Indeed there is data to support such concern. For example the variability in prevalence of CKD by practice within Sheffield PCT ranges between 0% and 9.8%. Whilst some of this variation undoubtedly reflects practice-population demographics it is likely that systems for identifying and monitoring CKD varies between practices. Similarly, only 65% of patients in Sheffield PCT achieved the combined QOF indicators of being on a CKD register and attaining target blood pressure.

Proposed model of care 

We aim to develop the renal database (Proton) at the Sheffield Kidney Institute (SKI) to allow remote monitoring of patients with CKD. This is being done at the moment with the Sheffield Central Consortium of GP practices.

The key changes we have implemented are:

1. Clinician-led CKD-Disease Management Program (CKD-DMP) specifying frequency of laboratory and blood pressure testing with individualised targets for care.
2. All patients suitable for CKD-DMP to have bloods taken in primary care and self-monitor blood pressure or have blood pressure taken in GP surgeries
3. To utilise a CKD nurse specialist to manage the remote data, liaise with patient and primary care physicians to replace clinic visits with a tele-consultation, reviewing clinical data with patient whilst maintaining care as set out by treatment targets in CKD-DMP.

Which personnel were involved?

CKD specialist nurse and consultant nephrologist in secondary care. Practice nurse in each surgery who acts as CKD link for specialist nurse

What was the timeframe?

Pilot started within 6 months of agreement between primary and secondary care.

Has the initiative been implemented elsewhere, before or since?

Not to our knowledge, though Bradford does have a well developed e-consultation service. This is different, being a remote monitoring and management service for chronic disease.

Sustainability benefits

The introduction of remote monitoring with tele-consultation has the potential to improve the targeting of specialist care resources (financial and environmental) to deliver the maximum value to patients.  By involving patients in self-monitoring, the model could potentially enhance patient empowerment in the management of their care, while reducing the need for travel as services are provided closer to home. 

The renal department at the Royal Cornwall Hospitals NHS Trust conducted a ten month pilot study of a Kidney Patient Results Review Monitoring Service from June 2011 to March 2012. Patients with chronic kidney disease (CKD) III and IV were managed in primary care with secondary care supervision of blood results. Funding was offered via the Southwest Peninsula Network to set up a ‘virtual’ CKD clinic. Our team took up this opportunity, recognising the particular benefits in Cornwall, where rural patients currently travel long distances. The lead consultant was Dr. Rob Parry, supported by PRMS nurse, Mel Geall.The model successfully reduced the number of patient visits to renal outpatients, saving on patient time and travel, without compromising care.

Benefits to environmental sustainability

During the pilot, a total of 135 patients came under the review service, 119 of them were reviewed, with 95 clinic visits being saved. Mileage between the patients’ homes and the hospital where they attended their renal outpatient clinic were calculated using the ‘RAC Routeplanner’ website. A total of 2,020 miles were ‘saved’ resulting in a saving of 2020 miles x 0.37604 kgCO2e per mile* = 760 kgCO2e

It is also worth noting that some patients would be travelling to their appointments by ambulance or hospital funded transport.Two patients, who live on the Isles of Scilly, used to be flown by helicopter for each visit.

* total GHG conversion factor for medium cars using unknown fuel, taken from Annex 6 (Passenger Transport) of Defra 2012 greenhouse gas conversion factors for company reporting, available from: http://www.defra.gov.uk/publications/2012/05/30/pb13773-2012-ghg-conversion/)

Cost benefit

Costs: The pilot had funding for 1 day/week Band 6 specialist nurse and 2 hours/week consultant time (approx. £10,000 in total).

Savings: 175 tests were reviewed remotely, saving 95 clinic visits at a tariff of £128* = £12,160.

* 2011-12 PbR tariff for follow up attendance in nephrology, single professional

The Chester Green Nephrology Local Representative has led the development of a business case to enable the haemodialysis unit to recycle its 'grey' reject water produced by the reverse osmosis plant, which provides the purified water for dialysate. The plant runs for 123 hours per week, producing between 8.7-14.2 litres litres waste water per minute, just under a quarter of the annual water consumption within the Trust. If the project is implemented, the water will be stored and used for a regeneration of the carbon filters within the treatment plant, number of toilets, a sluice area, and a laundry area located in the renal outpatients department.

The project has been inspired by a previous Green Nephrology case study which was presented at the British Renal Society conference in 2010. Following this, the Chester Green Nephrology Local Representative, Elizabeth Critchley, proposed the introduction of waste water recycling to the carbon reduction team in Chester, who showed a keen interest. The calculations for water savings have been made in conjunction with a local water company, which has also given a a quote for the works.

Other people who have been approached within the Trust include the Renal Unit Manager, the EBME manager (responsible for RO plant maintenance), and the Estates department. The business case has now been submitted to the Trust carbon reduction team, who are supportive and will present it to the Board.

The water company undertaking the future works will be responsible for fitting the water tank, piping and connections to the plant room, roof space, toilets, sluice and laundry area. This work will be performed overnight and on Sundays when the plant is not being used, to eliminate any risk to the water pressures during operational times as this could pose unnecessary risk to patients on dialysis.

Benefits to environmental sustainability

The forecasted water saving is 4,000 litres per day 1,460 cubic metres per annum. Daily saving usage:

• Water Reused by Carbon Filters - 1 backwash/day = 900 litres/day
• Water Reused by Softeners - 2 regenerations/3 days = 500 litres/day
• Available water for washing machines and toilet flushing = 2,600 litres/day

This amount equates to an approximate reduction in carbon emissions of 0.11648 tonnes CO2e per annum*.

Conversion factors used:

Water supply: 0.39 kgCO2/m3 - figure supplied by Welsh Water the Trust current water supplier

Sewerage: 0.17 kgCO2/m3 - figure supplied by the Environmental Agency

Financial benefits

The Trust will also make a financial saving of

• Tap Water: £1370.79 per annum (£0.9389 per m3 of water)
• Sewerage Services: £1773.17 per annum (£1.2145 per m3)
• Total Annual saving = £3143.96

The Trust will be making a financial investment of £11,030, therefore the retrofit will have paid for itself within 3 years 6 months.

The renal service decided to invest the full value of a BJRM Innovation in Renal Medicine Award 2011 prize (£5,000) in a  greener healthcare energy saving initiative. Following a site survey of the renal unit, the lighting project was chosen as the most appealing in terms of delivery, risk and savings. The survey revealed that the fluorescent light fittings were of a 'T8' type, whose energy consumption can be up to two times that of a modern 'T5' light fitting. Existing luminaires had started to degrade and could not produce all the expected light from the fluorescent tubes. Following a consultation exercise with  renal unit staff, a plan was agreed to install 'T5' light fittings. A total of 85 light fittings were changed in the Renal unit offices and wards.

The project was part of an on-going collaboration between the local Green Nephrology Champion and the Trust Estates department. The feasibility study, survey and business case were carried out by Mr Nsipa Siwale (Energy Manager). Activities included risk assessments, product selection, tendering and project management. Departmental support and funding was provided by Dr John Stoves. To minimise risks and disruption to staff and patients, most of the work was carried out after normal working hours.

Benefits to environmental sustainability

The annual operating hours for lighting in the Renal unit are 3,000 hours. The average energy saving per individual light is 36 kilowatt hours per year. Based on a greenhouse gas conversion factor of 0.58982 kgCO2e/kWh*, the project will save 11.5 tonnes of CO2e over 5 years.

* “All-scopes grid rolling average” emissions factor for electricity consumed (2010), Table 3c, Defra 2012 greenhouse gas conversion factors for company reporting

Heat exchangers have been retrofitted to all 21 BBraun Dialog+ Dialysis Machines for patients on home haemodialysis. The decision was taken to prioritise retrofit of home haemodialysis machines after analysis of temperature changes and power consumption in the home and dialysis unit settings. The colder incoming water in patients' homes in Winter, as compared with the water temperature in the dialysis centre, resulted in increased power consumption over all and greater energysavings from inclusion of the heat exchanger.

Benefits to environmental sustainability

Estimated energy/CO2 savings

Energy savings were estimated by comparing a standard cycle on a machine with heat exchanger to one without. Results in the dialysis unit showed 5.2 kWh vs. 4.7 kWh (with heat exchanger), a saving of 0.5 kWh per treatment, or approx. 10%.

However, electricity usage was almost 3x higher for a treatment at the home of a home-dialysing patient, where the incoming water temperature was 5C, as compared with 10-22C in the dialysis unit. Power consumption from the WRO and HD without heat exchanger was 14.05 kWh. Energy savings in this setting would be expected to be greater. Even a 10% saving would save 1.4kWh per treatment – 218.4kWh per year.

Actual savings to date

Initial recordings have been taken in the summer months with an incoming water temperature of approx. 18C. Under these conditions, retrofitting of the heat exchangers has reduced electricity consumption by 0.625kWh per treatment. For a typical patient on 3 treatments per week, if the energy saving remained constant, then total energy savings would be 0.625kWh x 3 x52 = 97.5 kWh. Carbon savings would be estimated as 97.5 x 0.58982* = 57.5 kg CO2e per year per machine, or 1.207 tonnes CO2e for all 21 machines.

However, energy savings are likely to increase in winter with lower water temperatures in patients' homes.

Additional Benefits

The 21 home dialysis patients will benefit from reduced electricity bills. This cost saving may in future be passed onto the renal service through a commensurate reduction in the financial support given towards patients' utility bills. At a standard domestic tariff of £0.16/kWh, the 0.625 kWh electricity saving equates to a cost saving of approx. 10p/ treatment, translating to £15.60/year per machine, or £327.60/year for all 21 machines. However, total energy consumption and energy savings from the heat exchangers are expected to increase in colder weather.

* GHG emission factor for electricity consumed (2010 grid rolling average), taken from 2012 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Table 3c)

Details of Implementation

Following contact from the Green Nephrology programme, highlighting environmental and cost savings achieved by retrofit of heat exchangers in Kent, Dr Suren Kanagasundaram (Renal Consultant and Newcastle Green Nephrology Local Representative) asked the renal technicians to investigate the business case for retrofitting heat exchangers locally.

45 machines were found to be suitable for retrofit. Because of the greater energy savings in the home setting and the availability of funding via the home dialysis conversion budget, the decision was taken to prioritise retrofit of all 21 home machines.  

The cost (approx. £4,700 (£223.70 per machine, including £7.50 labour costs)) was found from the home dialysis conversion budget. 

The Renal Unit produces huge amounts of waste plastic and cardboard during its clinical activities. In order to recycle this waste the Trust installed two new pieces of equipment. A cardboard baler was installed to service the whole Freeman Hospital site in March 2011, which allowed the Renal Unit’s cardboard to be baled and recycled. In November 2011 a smaller twin baler was also installed to crush and bale the segregated 5L acid bottles from each renal dialysis session. Cardboard and plastic bottle recycling has increased by over 90 tonnes and savings of over £7,000 have been achieved.

The project was initiated by consultant nephrologist, Dr Alison Brown, and modern matron, Julia Harding. Using the commitment shown by the renal department, the Trust Waste Officer was able to justify a business case and gain Executive approval.

Equipment comprises a Static Vertical Mill Sized Baler (MX600) on long term rental for cardboard, and a twin chamber compact baler (Compact 75) on two-year rental for dialysis 5L plastic bottles. Baled cardboard and bottles are collected by SITA UK (the Trust's general waste contractor).

Environmental Benefits

An estimated 12 tonnes of plastic bottle waste is produced by the renal department each year.  Recycling all of this will save approximately 3.168 tonnes CO2e per year (1).

The renal unit has also been contributing its flattened cardboard to the main Freeman Hospital cardboard baler.  Approximately 100 tonnes of cardboard waste is produced annually and recycling this saves an estimated 82 tonnes CO2e per year (2). Unfortunately we are not able to break this down to the specific amount of cardboard produced by the Renal Unit as all areas of the hospital feed into the main cardboard baler. 

Total carbon savings from recycling of plastic and cardboard are therefore approximately 85.2 tonnes CO2e per year.

Importantly, recycling materials also reduces the need for virgin resources for new products. Although the benefits of this are hard to quantify, we know that increasing the recycling of resources instead of just disposing of them makes sense.

Furthermore, the compaction saves on CO2e emissions from large waste vehicle movements, since the much smaller volumes can be more easily stored and therefore collected less frequently. 

(1)This is based on -230 kg CO2e per tonne of plastic recycled vs 34 kg CO2e per tonne of plastic sent to landfill (Annex 9, DEFRA 2011 Greenhouse Gas Conversion Factors for Company Reporting) 

(2) This is based on -240 kg CO2e per tonne of cardboard recycled vs 580 kg CO2e per tonne of cardboard sent to landfill (Annex 9, DEFRA 2011 Greenhouse Gas Conversion Factors for Company Reporting) 

Financial Benefits

The financial savings are summarised below:

During haemodialysis, creation of the dialysate fluid requires a concentrated acidic solution of known constituents to be drawn into the machine. This solution is diluted with a set volume of purified water from a reverse osmosis unit to achieve the correct concentration. Our Trust had previously used cans of acidic concentrate which require a 34:1 ratio of dilution, i.e. 1 part concentrate to 34 parts water. This 34:1 solution is supplied in a 6 litre can. The same final composition can also be achieved using an alternative acidic solution with a concentration of 44:1 after some minor technical adjustments to the dialysis machine. This 44:1 solution can be supplied in a 4.7 litre can. The can size of each of the solution concentrations reflect a reasonable diluted volume to comfortably supply a 4-4.5 hour dialysis treatment.

Details of implementation

As the four most commonly used solutions were not available in the smaller container, the manufacturer BBraun was approached to develop the specific solutions with a 44:1 concentration in the required size container for the same cost and to provide advice on the minor technical changes needed to the dialysis machines. 

The trust procurement and supplies department were consulted to arrange new product codes to be allocated to the new items when bulk ordering. 

The dialysis machines’ settings were subsequently adjusted accordingly by the trust renal technicians to allow safe operation with the higher concentrations of solution.

The Higher concentration (44 to 1) solutions have been available for some time, although there are still a significant amount of treatments around the UK using the 34 to 1 can option. Switching to the 44 to 1 concentration cans is a relatively easy process at negligible cost and may be a more simple method of reducing concentrate solution storage without procuring and maintaining a more costly central acid delivery system.

Higher concentration dialysis solutions (44 to 1) are also available from other manufacturers and can be used in alternative brands of dialysis machine.

Benefits to environmental sustainability: Reduction in greenhouse gas emissions from road transport

The concentrate is manufactured and transported by road from Glandorf, Germany to Sheffield and from Sheffield to Kent. An estimate of the carbon savings from transporting smaller volumes can be made as follows:

Reduction of concentrate used per treatment = 6 to 4.7 litre can = 1.3 litres

Reduction of concentrate used daily in the Trust = 200 x 1.3 litres = 260 litres

Reduction of concentrate used annually = 260 x 312 days = 81,120 litres

Thus approximate weight each year = 81.1 tonnes

Glandorf to Sheffield = 960 km

Sheffield to Canterbury = 374 km

Total distance= 1334 km

Approximate annual reduction in greenhouse gas emissions from road freight:

= 0.14993 * x 81.1(tonnes) x 1334(km) = 16,220 kg CO2e / year = 16.22 tonnes CO2e / year

(* 2012 Guidelines to Defra/DECC's GHG Conversion Factors for Company Reporting (Annex 7, Table 7e))

This case study builds on the Reducing Waste in the Dialysis Unit Queen Margaret Hospital, Dunfermline case study from April 2010 (http://map.greenerhealthcare.org/nhs-fife/reducing-waste-dialysis-unit-q...).

A Green Nurse role was established to promote awareness and education on environmental issues in the workplace and minimize landfill waste and inappropriate clinical waste. A waste management hierarchy was developed using the following in order of preference:

REDUCE – reduce the amount of waste produced in the first place (most favoured)

REUSE – using materials repeatedly where possible

RECYCLE – send used materials to make new material for use

RECOVERY – recover energy for waste

LANDFILL – safe disposal into landfill sites (least favoured)

STEP 1: Waste segregation

A major finding from Waste Watch Weeks in 2009-10 was a lack of formalised waste management procedures pre and post dialysis treatments. 2.9kg of waste was generated per dialysis treatment (40.3 tonnes / year). At the start of 2010, 100% of this was sent as clinical waste for incineration. This has a particularly detrimental impact on the environment because of the very high temperatures at which clinical waste must be incinerated. By April 2010 we had reduced this incinerated waste from 100% to 31%, with 69% now being directed into the domestic waste stream because it was not contaminated eg packaging, bicarbonate bags etc.

STEP 2. Recycling

Next, a Domestic Waste Audit was carried out, which identified most of the waste was paper and plastic. We collaborated with Fife Council to divert as much of this as possible from landfill. Domestic waste bins ie black bags were removed from the clinical area and replaced with recycling bins and 83% of domestic waste is now recycled. Grade 7 plastic (saline bags and bicarbonate bags) still remain a challenge but we hope Fife Council will be able to take these soon. Education on environmental good practice is now included in our nurse education programme.

Financial Considerations

The creation of a ‘Green Nurse’ with protected time has been central to the success fo this project. Initial funding for this came via NHS Education for Scotland and the Scottish Renal Association. Fife Council provided recycling bins for free. Diverting clinical waste which is expensive to dispose of into the cheaper, domestic stream saved us £11,273 annually. Removing unnecessary consumables saved a further £24,900 annually. The cost for domestic waste disposal after recycling was £454.74 annually. Overall £35,718 annual saving.

Carbon Savings

Initially 72.5 tonnes CO2e was generated form the incineration of our clinical waste. Which was reduced to 22.5 tonnes CO2e a saving of 50 tonnes CO2e annually. After recycling, 4.7 tonnes of domestic waste was put into landfill. Assuming this was mostly grade 7 plastic, 14.8 tonnes CO2e would be generated by this (this is an over estimate as a proportion was kitchen waste). 23 tonnes of paper and plastic was recycled saving 21.1 tonnes CO2e giving an overall annual saving of 56.3 tonnes CO2e. 

Queen Margaret Hospital (QMH)  has 24 in-patient beds, 20 dialysis stations and serves a population of 350,000. Prior to the end of 2010 all intravenous (IV) antibiotics were given by infusion even where bolus could be safely used. This used a great deal of plastic. Additionally semi-prepared ‘mini-bags’ (designed for use in the community) were being used for convenience which was unnecessary.

To determine if savings were possible a retrospective analysis of antibiotic use, cost and carbon emissions was performed based on pharmacy records over a one-year period (October 2009–September 2010). Savings were then calculated assuming a similar pattern of antibiotic use, price and nursing staff time, but assuming infusion is replaced by bolus administration. 13 antibiotics were identified as suitable for bolus administration after pharmacy review. Antibiotics requiring infusion were excluded from the analysis leaving a total of 6,175 doses infused. The financial and carbon saving (below) were large and steps were taken to change practice. Staff were educated to deliver drugs safely by bolus and a suitable preparation area was identified. Practice was changed from the beginning of 2011 with audit planned. This has been easily adopted by staff and there have been no safety concerns to date but maintining practice has been challenging.

Background

The NHS has an increasing chronic care burden and must conform to the NHS carbon reduction strategy in a time of relative funding reduction. Procurement forms a significant component of the NHS budget and 60% of the NHS carbon footprint. This rises to 72% for renal services where equipment and pharmaceutical use is high. Reducing procurement emissions is a ‘quick win’ and systematic analysis of clinical processes can identify non-essential consumables and provide opportunities to lean treatment pathways that will deliver both cost and carbon savings.

Financial Considerations

This project incurred no additional cost to the NHS being funded entirely by staff enthusiasm where extra work was required. All training could be provided ‘in-house’.

Excluding drug costs, infusion via an infusion pump cost £1.96 per administration (pump administration set, £1.38; 50-100mls sodium chloride or dextrose bag, £0.35; 20ml syringe, £0.09; 21G needle x2, £0.04; Alcowipes x2, £0.01) verses £0.22 for bolus administration (10ml syringe, £0.12; 10ml sodium chloride, £0.045; 21G needle x2, £0.04; Alcowipes x2, £0.01). The total cost, including ‘mini-bags’ was £11,158. Assuming identical antibiotic use the predicted annual cost saving was £9,830 (88.1%). Savings from reduced disposal (0.41 tonnes equipment waste saved) by incineration are estimated at £165 annually (assuming a cost of £400 per tonne) bringing the total saving to £9,995 per year. In addition to consumables, further annual drug cost savings of £7065.33 were made by purchasing vials for bolus administration rather than pre-prepared mini-bags for infusion bringing the overall total saving to £17,060 annually.

Carbon Savings

Supply chain emissions saved (manufacture, transport etc):

• Equipment: £9830 x 0.30 kg CO2e / £ * = 2949 kg CO2e
• Drug: £7065 x 0.43 kg CO2e / £ * = 3038 kg CO2e

Emissions saved from avoided incineration of plastic waste:

• 0.406 tonnes plastic x 1833 kg CO2e / tonne ** = 744 kg CO2e

Total emissions saved, per year: 

• 2949 + 3038 + 744 = 10,020 kg CO2e, or 6.73 tonnes CO2e

* Greenhouse gas (GHG) conversion factors for supply chain were obtained from the 2012 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Annex 13).

** Greenhouse gas (GHG) conversion factors for waste incineration were obtained from the 2011 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Table 9d).

GETTING STARTED – ‘HOW TO’ GUIDE 

1. Ascertain current practice by auditing antibiotic use and administration methods on the ward – are you missing opportunities to reduce infusions?
2. Involve senior nursing, medical and pharmacy staff early on.
3. Patient safety is the first priority – confirm drugs which can safely be given by bolus and how this is done. Set out clear procudures that can be easily accessed in the preperation area.
4. Identify an areas for bolus preparation if not already in existence.
5. Listen to staff concerns and address these through education and training as needed.
6. Ensure adequate numbers of trained staff are on the ward so that drugs can be administered as boluses on every shift.
7. Set a start date which everyone is aware of.
8. Measure the outcome by audit and staff feedback.

Further tips

Savings could be amplified if IV bolus administration was adopted as standard practice across NHS specialties and for all IV drugs suitable for this route of administration.